Subscribe to RSS
DOI: 10.1055/a-2043-4451
Postpartale Hämorrhagie
Postpartum HemorrhageDie postpartale Hämorrhagie tritt bei etwa 4% aller Entbindungen in industrialisierten Ländern auf und zeigt eine steigende Inzidenz. Die schwerwiegenden Auswirkungen auf das maternale Outcome erfordern eine rasche Diagnosestellung und Ursachenidentifizierung mit nachfolgendem zielgerichtetem sowie interdisziplinärem Management der Blutstillung, Kreislaufstabilisierung und Gerinnungstherapie.
Abstract
Postpartum hemorrhage (PPH) affects about 4% of all deliveries in high-income countries and continues to rise, a trend attributable to the increase in caesarean section rates and maternal morbidity. Preventive measures such as the precautionary administration of uterotonics effectively reduce the risk of severe bleeding irrespective of birth mode. As a time-critical condition and a significant contributor to adverse maternal outcomes, PPH needs to be diagnosed early by measuring, not estimating, blood losses. Institutional treatment algorithms should be available to guide stage-based interdisciplinary management without delay. The main therapy goals are to identify the etiology and stop the bleeding by using uterotonics and mechanical and surgical interventions, to restore hemodynamic stability by volume and transfusion therapy and to optimize hemostasis by laboratory- and viscoelastic assay-guided factor replacement. This review highlights current recommendations for prevention, diagnosis and treatment of PPH.
-
Von einer peripartalen Hämorrhagie spricht man in der DACH-Region bei einem Blutverlust von > 500 ml nach vaginaler Geburt, > 1000 ml nach Sectio caesarea oder klinischen Zeichen eines hämorrhagischen Schocks.
-
Mit Diagnosestellung sollte umgehend 1 g Tranexamsäure gegeben werden.
-
Anhaltende schwere Blutungen erfordern ein interdisziplinäres Management, das in klinikinternen stadienbasierten Handlungsalgorithmen klar formuliert sein sollte.
-
Oxytocin stellt das Uterotonikum der ersten Wahl zur Therapie der PPH dar, bei unzureichender Wirkung sollte rasch auf Sulproston umgestellt werden.
-
Zur Prävention der PPH nach Schnittentbindung kommen Carbetocin (100 µg) oder Oxytocin zur Anwendung, bevor auch hier auf Sulproston gewechselt werden sollte.
-
Die Uterustamponade wird sowohl zur Überbrückung als auch als definitive Therapie der PPH, z. B. in Kombination mit Kompressionsnähten, angewendet.
-
Operative Techniken umfassen uterine Kompressionsnähte, Gefäßligaturen sowie die Hysterektomie als Ultima Ratio.
-
Der Einsatz interventionell-radiologischer Maßnahmen ist sowohl bei antizipiertem als auch manifestem Blutverlust möglich, wird jedoch durch die jeweilige lokale Verfügbarkeit eingeschränkt.
-
Volumen- und Transfusionstherapie sollten initial empirisch begonnen werden, dann jedoch möglichst rasch durch bettseitige und laborbasierte Parameter gezielt gesteuert werden.
-
Die Substitution von Gerinnungsfaktoren bei Auftreten einer Koagulopathie sollte aufgrund der schwangerschaftsbedingten Hämostaseveränderungen möglichst individualisiert unter Berücksichtigung von Faktorenbestimmungen und viskoelastischen Tests erfolgen.
Schlüsselwörter
postpartale Blutung - vaginale Geburt - Kaiserschnitt - Uterusatonie - KoagulopathiePublication History
Article published online:
13 October 2023
© 2023. Thieme. All rights reserved.
Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany
-
Literatur
- 1 World Health Organization (WHO). Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. 2023 Accessed July 28, 2023 at: https://www.who.int/publications/i/item/9789240068759
- 2 Say L, Chou D, Gemmill A. et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014; 2: e323-e333 DOI: 10.1016/S2214-109X(14)70227-X. (PMID: 25103301)
- 3 Reale SC, Easter SR, Xu X. et al. Trends in postpartum hemorrhage in the United States from 2010 to 2014. Anesth Analg 2020; 130: e119-e122 DOI: 10.1213/ANE.0000000000004424.
- 4 Kramer MS, Berg C, Abenhaim H. et al. Incidence, risk factors, and temporal trends in severe postpartum hemorrhage. Am J Obstet Gynecol 2013; 209: 449.e1-449.e7 DOI: 10.1016/j.ajog.2013.07.007.
- 5 Corbetta-Rastelli CM, Friedman AM, Sobhani NC. et al. Postpartum hemorrhage trends and outcomes in the United States, 2000–2019. Obstet Gynecol 2023; 141: 152-161 DOI: 10.1097/AOG.0000000000004972. (PMID: 36701615)
- 6 Leitlinienprogramm DGGG, OEGG, SGGG. Peripartale Blutungen, Diagnostik und Therapie. S2k-Level, AWMF-Registernummer 015/063. August 2022 Accessed July 28, 2023 at: https://register.awmf.org/assets/guidelines/015–063l_S2k_Peripartale_Blutungen_Diagnostik_Therapie_PPH_2022–09_2.pdf
- 7 Abdul-Kadir R, McLintock C, Ducloy A-S. et al. Evaluation and management of postpartum hemorrhage: consensus from an international expert panel. Transfusion 2014; 54: 1756-1768 DOI: 10.1111/trf.12550. (PMID: 24617726)
- 8 Begley CM, Gyte GM, Devane D. et al. Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev 2019; (02) CD007412 DOI: 10.1002/14651858.CD007412.pub5. (PMID: 30754073)
- 9 Gallos ID, Papadopoulou A, Man R. et al. Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis. Cochrane Database Syst Rev 2018; (12) CD011689 DOI: 10.1002/14651858.CD011689.pub3.
- 10 Heesen M, Carvalho B, Carvalho JCA. et al. International consensus statement on the use of uterotonic agents during caesarean section. Anaesthesia 2019; 74: 1305-1319 DOI: 10.1111/anae.14757. (PMID: 31347151)
- 11 Gallos I, Devall A, Martin J. et al. Randomized trial of early detection and treatment of postpartum hemorrhage. N Engl J Med 2023; 389: 11-21 DOI: 10.1056/NEJMoa2303966. (PMID: 37158447)
- 12 Onwochei DN, Owolabi A, Singh PM. et al. Carbetocin compared with oxytocin in non-elective Cesarean delivery: a systematic review, meta-analysis, and trial sequential analysis of randomized-controlled trials. Can J Anaesth 2020; 67: 1524-1534 DOI: 10.1007/s12630-020-01779-1. (PMID: 32748189)
- 13 Moertl MG, Friedrich S, Kraschl J. et al. Haemodynamic effects of carbetocin and oxytocin given as intravenous bolus on women undergoing caesarean delivery: a randomised trial. BJOG 2011; 118: 1349-1356 DOI: 10.1111/j.1471-0528.2011.03022.x. (PMID: 21668768)
- 14 Neef V, Wenk M, Kranke P. Geburtshilfliche Anästhesie. Anästhesiol Intensivmed Notfallmed Schmerzther 2023; 58: 570-582 DOI: 10.1055/a-2043-4329.
- 15 Pacagnella RC, Souza JP, Durocher J. et al. A systematic review of the relationship between blood loss and clinical signs. PLoS One 2013; 8: e57594 DOI: 10.1371/journal.pone.0057594. (PMID: 23483915)
- 16 Bose P, Regan F, Paterson-Brown S. Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions. BJOG 2006; 113: 919-924 DOI: 10.1111/j.1471-0528.2006.01018.x. (PMID: 16907938)
- 17 Suarez S, Conde-Agudelo A, Borovac-Pinheiro A. et al. Uterine balloon tamponade for the treatment of postpartum hemorrhage: a systematic review and meta-analysis. Am J Obstet Gynecol 2020; 222: 293.e1-293.e52 DOI: 10.1016/j.ajog.2019.11.1287.
- 18 Ibrahim M, Ziegler C, Klam SL. et al. Incidence, indications, and predictors of adverse outcomes of postpartum hysterectomies: 20-year experience in a tertiary care centre. J Obstet Gynaecol Can 2014; 36: 14-20 DOI: 10.1016/S1701-2163(15)30679-4. (PMID: 24444283)
- 19 Chan L-L, Lo T-K, Lau W-L. et al. Use of second-line therapies for management of massive primary postpartum hemorrhage. Int J Gynaecol Obstet 2013; 122: 238-243 DOI: 10.1016/j.ijgo.2013.03.027. (PMID: 23806248)
- 20 Al Riyami N, Hui D, Herer E. et al. Uterine compression sutures as an effective treatment for postpartum hemorrhage: case series. AJP Rep 2011; 1: 47-52 DOI: 10.1055/s-0031-1280570. (PMID: 23705085)
- 21 Doumouchtsis SK, Nikolopoulos K, Talaulikar V. et al. Menstrual and fertility outcomes following the surgical management of postpartum haemorrhage: a systematic review. BJOG 2014; 121: 382-388 DOI: 10.1111/1471-0528.12546. (PMID: 24321038)
- 22 Chai VYK, To WWK. Uterine compression sutures for management of severe postpartum haemorrhage: five-year audit. Hong Kong Med J 2014; 20: 113-120 DOI: 10.12809/hkmj134023. (PMID: 24141858)
- 23 O’Leary JA. Uterine artery ligation in the control of postcesarean hemorrhage. J Reprod Med 1995; 40: 189-193 (PMID: 7776302)
- 24 Abbassi-Ghanavati M, Greer LG, Cunningham FG. Pregnancy and laboratory studies: a reference table for clinicians. Obstet Gynecol 2009; 114: 1326-1331 DOI: 10.1097/AOG.0b013e3181c2bde8. (PMID: 19935037)
- 25 Lockwood CJ. Pregnancy-associated changes in the hemostatic system. Clin Obstet Gynecol 2006; 49: 836-843 DOI: 10.1097/01.grf.0000211952.82206.16. (PMID: 17082678)
- 26 Moore HB, Moore EE, Liras IN. et al. Acute fibrinolysis shutdown after injury occurs frequently and increases mortality: a multicenter evaluation of 2,540 severely injured patients. J Am Coll Surg 2016; 222: 347-355 DOI: 10.1016/j.jamcollsurg.2016.01.006. (PMID: 26920989)
- 27 WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet 2017; 389: 2105-2116 DOI: 10.1016/S0140-6736(17)30638-4. (PMID: 28456509)
- 28 Sentilhes L, Sénat MV, Le Lous M. et al. Tranexamic acid for the prevention of blood loss after cesarean delivery. N Engl J Med 2021; 384: 1623-1634 DOI: 10.1056/NEJMoa2028788. (PMID: 33913639)
- 29 Pacheco LD, Clifton RG, Saade GR. et al. Tranexamic acid to prevent obstetrical hemorrhage after cesarean delivery. N Engl J Med 2023; 388: 1365-1375 DOI: 10.1056/NEJMoa2207419. (PMID: 37043652)
- 30 Ducloy-Bouthors A-S, Gilliot S, Kyheng M. et al. Tranexamic acid dose-response relationship for antifibrinolysis in postpartum haemorrhage during Caesarean delivery: TRACES, a double-blind, placebo-controlled, multicentre, dose-ranging biomarker study. Br J Anaesth 2022; 129: 937-945 DOI: 10.1016/j.bja.2022.08.033.
- 31 Hurskainen T, Deng MX, Etherington C. et al. Tranexamic acid for prevention of bleeding in cesarean delivery: An overview of systematic reviews. Acta Anaesthesiol Scand 2022; 66: 3-16 DOI: 10.1111/aas.13981. (PMID: 34514595)
- 32 Lier H, Krep H, Schroeder S. et al. Preconditions of hemostasis in trauma: a review. The influence of acidosis, hypocalcemia, anemia, and hypothermia on functional hemostasis in trauma. J Trauma 2008; 65: 951-960 DOI: 10.1097/TA.0b013e318187e15b. (PMID: 18849817)
- 33 Talati C, Ramachandran N, Carvalho JCA. et al. The effect of extracellular calcium on oxytocin-induced contractility in naive and oxytocin-pretreated human myometrium in vitro. Anesth Analg 2016; 122: 1498-1507 DOI: 10.1213/ANE.0000000000001264. (PMID: 27023765)
- 34 Litvinov RI, Weisel JW. Role of red blood cells in haemostasis and thrombosis. ISBT Sci Ser 2017; 12: 176-183 DOI: 10.1111/voxs.12331. (PMID: 28458720)
- 35 Kozek-Langenecker SA, Ahmed AB, Afshari A. et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology: First update 2016. Eur J Anaesthesiol 2017; 34: 332-395 DOI: 10.1097/EJA.0000000000000630. (PMID: 28459785)
- 36 Yan H, Hu L-Q, Wu Y. et al. The association of targeted cell salvage blood transfusion during cesarean delivery with allogeneic packed red blood cell transfusions in a maternity hospital in China. Anesth Analg 2018; 127: 706-713 DOI: 10.1213/ANE.0000000000003303.
- 37 Mesar T, Larentzakis A, Dzik W. et al. Association between ratio of fresh frozen plasma to red blood cells during massive transfusion and survival among patients without traumatic injury. JAMA Surg 2017; 152: 574-580 DOI: 10.1001/jamasurg.2017.0098. (PMID: 28273299)
- 38 Inaba K, Branco BC, Rhee P. et al. Impact of plasma transfusion in trauma patients who do not require massive transfusion. J Am Coll Surg 2010; 210: 957-965 DOI: 10.1016/j.jamcollsurg.2010.01.031. (PMID: 20510805)
- 39 Collis RE, Collins PW. Haemostatic management of obstetric haemorrhage. Anaesthesia 2015; 70 (Suppl. 01) 78-86 DOI: 10.1111/anae.12913. (PMID: 25440400)
- 40 Ducloy-Bouthors A, Mercier F, Grouin J. et al. Early and systematic administration of fibrinogen concentrate in postpartum haemorrhage following vaginal delivery: the FIDEL randomised controlled trial. BJOG 2021; 128: 1814-1823 DOI: 10.1111/1471-0528.16699. (PMID: 33713384)
- 41 Collins PW, Cannings-John R, Bruynseels D. et al. Viscoelastometric-guided early fibrinogen concentrate replacement during postpartum haemorrhage: OBS2, a double-blind randomized controlled trial. Br J Anaesth 2017; 119: 411-421 DOI: 10.1093/bja/aex181. (PMID: 28969312)
- 42 Wikkelsø AJ, Edwards HM, Afshari A. et al. Pre-emptive treatment with fibrinogen concentrate for postpartum haemorrhage: randomized controlled trial. Br J Anaesth 2015; 114: 623-633 DOI: 10.1093/bja/aeu444. (PMID: 25586727)
- 43 Bell SF, Roberts TCD, Freyer Martins Pereira J. et al. The sensitivity and specificity of rotational thromboelastometry (ROTEM) to detect coagulopathy during moderate and severe postpartum haemorrhage: a prospective observational study. Int J Obstet Anesth 2022; 49: 103238 DOI: 10.1016/J.IJOA.2021.103238. (PMID: 34840018)
- 44 Roberts TCD, De Lloyd L, Bell SF. et al. Utility of viscoelastography with TEG 6s to direct management of haemostasis during obstetric haemorrhage: a prospective observational study. Int J Obstet Anesth 2021; 47: 103192 DOI: 10.1016/j.ijoa.2021.103192. (PMID: 34144351)
- 45 Solomon C, Pichlmaier U, Schoechl H. et al. Recovery of fibrinogen after administration of fibrinogen concentrate to patients with severe bleeding after cardiopulmonary bypass surgery. Br J Anaesth 2010; 104: 555-562 DOI: 10.1093/bja/aeq058. (PMID: 20348140)
- 46 Haslinger C, Korte W, Hothorn T. et al. The impact of prepartum factor XIII activity on postpartum blood loss. J Thromb Haemost 2020; 18: 1310-1319 DOI: 10.1111/jth.14795. (PMID: 32176833)
- 47 Lavigne-Lissalde G, Aya AG, Mercier FJ. et al. Recombinant human FVIIa for reducing the need for invasive second-line therapies in severe refractory postpartum hemorrhage: a multicenter, randomized, open controlled trial. J Thromb Haemost 2015; 13: 520-529 DOI: 10.1111/jth.12844. (PMID: 25594352)
- 48 Simpson E, Lin Y, Stanworth S. et al. Recombinant factor VIIa for the prevention and treatment of bleeding in patients without haemophilia. Cochrane Database Syst Rev 2012; (03) CD005011 DOI: 10.1002/14651858.CD005011.pub4.